Prior authorization required (trial criteria must be met)

Prior authorization is required before proceeding to permanent implantation; approval is contingent on documentation that all applicable short-term trial criteria for the indication have been met prior to permanent SCS placement.

Prior authorization for trial and permanent implant

Obtain prior authorization for both the short-term trial and any request for permanent implantation; submit documentation that all short-term trial criteria were met and, for permanent implantation, that the trial produced the required pain relief.

Prior authorization for permanent implantation

For permanent implantation of a non-high-frequency dorsal column SCS, prior authorization requires documentation that all short-term trial criteria were met and that the trial produced the required pain relief.

Trial success required before permanent implantation (≥50% relief)

Prior authorization for permanent implantation must confirm a documented short-term trial demonstrating at least 50% pain relief and that all criteria for the short-term trial were satisfied.

• Trial success threshold: ≥50% documented pain relief during trial

Prior authorization implied for nonstandard devices/modes

Prior authorization is implied for replacement/upgrades and for use of generator modes or DRG placement because these are designated investigational or not medically necessary under the policy, and such requests will require explicit authorization review.

• Replacement of a functioning non-high-frequency device with a high-frequency device is considered not medically necessary (may require review).
• Generator modes other than tonic-low and high-frequency (e.g., burst) and DRG placement are considered investigational.

Prior authorization for permanent SCS (multidisciplinary evaluation required)

Prior authorization is required for permanent SCS implantation after a successful short-term trial and must document prior multidisciplinary evaluation and failed or unsuitable prior treatments.

• Multidisciplinary screening/evaluation (psychological assessment when indicated) must be documented.

Temporary trial required (document duration and ≥50% relief)

A temporary short-term trial demonstrating ≥50% pain relief is required before permanent SCS implantation; providers must document the trial duration and quantified pain response.

• Trial duration requirement: at least >48 hours (general) or at least 5 days for PDPN in policy sections

SCS trial and device-specific authorization

A trial of SCS is generally recommended before permanent implant (exception: chronic anginal pain in nonsurgical candidates); device-specific authorization may be affected by regulatory approvals for closed-loop, DRG, and high-frequency systems.

• Require ≥50% pain relief on a validated instrument when a trial is performed.
• Device-specific regulatory status (e.g., HF10, DRG, closed-loop) may influence authorization.

Prior authorization: include relevant CPT/HCPCS procedure and device codes

Use the policy-listed CPT and HCPCS codes when submitting authorization and billing requests for SCS/DRG procedures, including implantation, revision, removal, and generators; code lists in the policy should be referenced but may not be exhaustive.

• Examples: CPT 63650, 63655, 63661, and HCPCS C1820, C1822, L8680, L8685 (see policy code tables).

Prior authorization requirement tied to product benefit coverage

When a product covers SCS services, the medical policy criteria must be met for coverage; prior authorization is implied to ensure criteria are satisfied under the member's product benefits.

• Services are contract dependent; if a product does not cover a service, medical policy criteria do not apply.

Conservative therapy and medication trials required before trial

Document failure or intolerance to an adequate course of conservative management prior to trial: for FBSS, at least six consecutive months of physician-supervised conservative medical management; for PDPN, ineffective relief or intolerance to at least two medication classes.

• FBSS: ≥6 months of conservative management (pharmacotherapy, PT, CBT, activity/lifestyle modification).
• PDPN: failure/intolerance to ≥2 medication classes (anticonvulsants, TCAs, SNRIs, or opioids with limits).

Conservative therapy requirement: document ≥2 failed/intolerant therapies

Document ineffective pain relief with or intolerance to at least two conservative treatments prior to authorizing an SCS trial; if opioids are used, document daily use ≤100 MME/day.

• Examples of conservative treatments include opioids (with MME documentation), anticonvulsants, TCAs, SNRIs.

Conservative therapy duration required (≥6 months)

Failure of at least six consecutive months of physician-supervised conservative medical management (pharmacotherapy, physical therapy, CBT, or activity/lifestyle modification) must be documented prior to consideration of SCS for applicable indications.

Optimal medical therapy required prior to short-term trial (angina)

For chronic angina indications, document failure to adequately improve with optimal medical therapy (OMT) including antiplatelet therapy, statin/lipid-lowering therapy, anti-anginal therapy to pursue HR goal ~60 bpm, and antihypertensive therapy pursuing SBP ≤140 and DBP ≤90 prior to a short-term trial.

• Treating cardiologist attestation confirming CAD diagnosis and that the patient is not a candidate for revascularization is required.

Repeat trial restriction: no repeat trial after failed initial trial

A repeat short-term trial is not allowed after a failed initial short-term trial; do not request authorization for repeat trials following a failed trial.

Step therapy / last-resort requirement before permanent implantation

Permanent SCS implantation is reserved as a last-resort measure after pharmacological, surgical, psychological, or physical treatments have been tried and failed or are judged unsuitable/contraindicated; document prior treatment attempts.

Conservative therapy failure prerequisite (PDN: refractory to gabapentinoids + another class)

Policy requires that patients selected for SCS have failed conservative management; for PDN, document refractoriness to gabapentinoids and at least one other analgesic class per the SENZA-PDN study eligibility referenced.

• Document medication classes tried and responses (e.g., gabapentinoids, SNRIs, TCAs).

Exhaust guideline-recommended conservative therapies before SCS

Guidelines recommend exhausting appropriate pharmacologic and noninvasive therapies for conditions such as PDN before considering SCS; document guideline-based prior treatments.

• Follow AACE/ASPN recommendations for medication classes and nonpharmacologic approaches.

Revised conservative treatment criteria remain prerequisite

Conservative treatment criteria were revised and remain prerequisites in the coverage pathway; ensure documentation reflects the current policy-conservative therapy requirements.

Required documentation: behavioral health attestation, trial results, HbA1c (PDN)

Include a behavioral health attestation (face-to-face or virtual assessment, with or without questionnaires/testing) confirming no inadequately controlled mental/behavioral health conditions that would impact pain perception or SCS success, and record trial pain relief (≥50%) and recent HbA1c (<10% within 3 months) when applicable for PDN.

• Behavioral health attestation required prior to trial and implantation.
• For PDN: document HbA1c <10% within 3 months prior to trial.

Required documentation: attest behavioral health, short-term trial criteria, ≥50% relief

Require behavioral health attestation (face-to-face or virtual, with or without questionnaires/testing), documentation that all short-term trial criteria were met for permanent implantation, and documentation of ≥50% pain relief during the short-term trial.

• Document that all short-term trial elements (indication, conservative therapy failures, exclusion of other diagnoses) were met.

Behavioral health attestation required

Behavioral health attestation must be provided by a behavioral health provider documenting no inadequately controlled behavioral health condition that would impact pain perception or SCS success (face-to-face or virtual assessment, with or without questionnaires/testing).

Vascular surgeon attestation required for CLI

For chronic critical limb ischemia (CLI) indications, include an attestation from a vascular surgeon that the individual is not a suitable candidate for vascular reconstruction as part of trial eligibility documentation.

Cardiologist attestation required for angina indication

For refractory angina indications, include an attestation by the treating cardiologist confirming coronary artery disease diagnosis and that the patient is not a suitable candidate for revascularization; include behavioral health attestation as required.

Device revision documentation required for electrode revisions

When applicable, documentation must show revision of the electrode percutaneous array(s) or electrode plate/paddle(s) is required for replacement or revision requests.

Required evaluation and trial documentation (multidisciplinary screening + trial results)

Submit multidisciplinary screening/evaluation documentation (including psychological assessment if indicated) and the short-term trial results (duration, quantified pain relief) as part of an authorization or implant request.

• Include presurgical psychological evaluation when applicable.

Required documentation for SCS trial and evaluation (duration, ≥50% relief, psychosocial screening)

For SCS trial and evaluation documentation, include trial duration (≥48 hours or ≥5 days where specified), quantified pain relief (trial success defined as ≥50% pain relief), and psychosocial screening results.

• Record validated instrument scores and percent pain reduction during trial.

Required clinical documentation: validated trial results and psychosocial screening

Clinical documentation must include trial results (≥50% pain relief on a validated instrument when a trial is performed), screening for psychosocial factors (including depression), and notation of contraindications such as untreated addiction or poorly controlled psychiatric disorders.

• Contraindications to note: untreated drug addiction, poorly controlled psychiatric disorders, pregnancy, repeating a failed trial in same region.

Coding and documentation: include CPT/HCPCS/ICD-10 references

Reference the policy's CPT, HCPCS, and ICD-10 code sections when submitting authorization and billing; note that code lists may not be exhaustive and updates may occur more frequently than policy.

• Policy lists codes but may not include every applicable code—verify current AMA/CMS coding.

Verify benefit and product coverage prior to authorization

Confirm that the member's benefit/product covers SCS services; if the product does not cover the service, medical policy criteria do not apply and coverage will be denied under that product.

• If a commercial, Medicaid, or Medicare product covers the service, follow medical policy criteria for documentation and authorization.

Denial risk: missing trial/implantation criteria or documentation

Requests may be denied if trial or implantation criteria are not met, including absence of required conservative treatment duration, missing behavioral health attestation, or failure to meet indication-specific criteria.

• Ensure all short-term trial elements and conservative therapy history are documented to avoid denial.

Triggers for potential denial: insufficient conservative therapy, metabolic or opioid thresholds, missing attestations

Denial risk is increased if the patient lacks documentation of at least two failed/intolerant conservative therapies, has HbA1c ≥10% within 3 months for PDN, exceeds opioid limits (>100 MME/day), or lacks behavioral health attestation.

• PDN-specific requirements: HbA1c <10% within 3 months, failure of ≥2 medication classes, VAS ≥5, trial duration ≥5 days.

Exclude alternative diagnoses concordant with symptoms

Coverage may be precluded if another medical or psychological diagnosis explains the presenting symptoms; documentation should exclude such alternate diagnoses with relevant studies.

• Review and document imaging, electrodiagnostic testing, and laboratory testing to exclude concordant diagnoses (e.g., CIDP, HIV, Lyme, chemo-induced neuropathy).

Not medically necessary: replacement to high-frequency device

Replacement of a functioning non-high-frequency dorsal column stimulator with a high-frequency stimulator is considered not medically necessary and may be denied.

Denial triggers: replacement to HF device, repeat trial, investigational DRG replacement

Denial triggers include replacement of a functioning non-high-frequency stimulator with a high-frequency stimulator, requesting a repeat short-term trial after an initial failed trial, or replacing dorsal column stimulation with DRG stimulation where investigational.

Investigational PNS/PNFS: potential denial risk

Use of peripheral nerve stimulation or peripheral nerve field stimulation for acute or chronic pain conditions is considered investigational and may be denied; do not request coverage for investigational indications without prior confirmation.

Trial requirement: document ≥50% trial relief to authorize permanent implant

Failure to document a temporary trial demonstrating ≥50% pain relief prior to permanent implantation may trigger denial of the permanent implant request.

Infection and contraindication considerations (limit trial duration ≤10 days)

Trials longer than 10 days are not ordinarily recommended because of increased infection risk; repeated failed SCS trials in the same region are contraindications—document trial duration and avoid extended trials.

• Trial duration: do not routinely exceed 10 days due to infection risk.

Coding may not guarantee coverage under all circumstances

Policy notes that codes may not be covered under all circumstances; verify coding applicability and coverage before submission.

Contract coverage dependency: confirm product benefits

Services are contract dependent; verify the member's product benefits because if the product does not cover the service, medical policy criteria do not apply and the request may be denied.

Document pre‑trial evaluation and relevant imaging/testing

Pre‑trial evaluation should include review of relevant studies (imaging, electrodiagnostics, labs) as indicated to exclude alternate diagnoses; document any imaging or testing performed.

• For CLI trials, advanced imaging (angiographic, CT, or MRI) is required to demonstrate multi‑level disease with absent named vessel flow into the foot.

Perform and document individualized pre‑trial evaluations

Perform indicated pre‑trial evaluations per patient presentation and document findings prior to trial authorization.

CLI trials require angiographic/CT/MRI and vascular surgeon attestation

For CLI short‑term trials, advanced imaging (angiographic, CT, or MRI) must demonstrate multi‑level disease with absence of named vessel flow into the foot; include vascular surgeon attestation.

Document fluoroscopic guidance for lead placement

Fluoroscopy is used for SCS and DRG lead placement; document imaging guidance used during lead placement in procedural records.

• Include fluoroscopy use in operative/procedure notes for percutaneous lead placement and DRG targeting.

Document fluoroscopy for percutaneous lead/DRG placement

Percutaneous lead placement and DRG stimulation are performed under fluoroscopic guidance; include this in procedural documentation when applicable.

Document guideline‑recommended pre‑procedure and psychosocial screening

Professional guidelines recommend standard pre‑procedure evaluations and psychosocial screening; document these evaluations even when no specific imaging mandate is present in the policy excerpt.

Document imaging guidance used for implantation/removal/revision when performed

When implantation, removal, or revision of neurostimulator electrode arrays and pulse generators is performed, document whether imaging guidance (fluoroscopy) was used 'when performed' as noted in CPT descriptions.

Document imaging used for selection or follow‑up when applicable

Clinical studies and guidelines referenced in the policy may include imaging as part of patient selection and follow‑up; if imaging was used for selection or follow‑up, document it in the record.